Reference no: EM133181050

ICD-10-CM Diagnosis Coding

Congenital Conditions  Chapter 25 AHA Coding Handbook

Directions: List as many codes as apply to each problem using the official coding guidelines, rules and conventions and UHDDS reporting guidelines. Place your code(s) in the correct sequence. Code the following as inpatient or outpatient setting as indicated in the problem.  Do not code procedures. 

Inpatient admission

1. The 27 year old patient was admitted for a cardiac pacemaker implant for her atrioventricular heart block, presumably congenital. A skin incision into the chest wall was made, and a dual chamber synchronous pacemaker was inserted into a subcutaneous pocket. The right atrioventricular transvenous leads were inserted percutaneously. She was on bed rest until she was stable and then discharged.

Discharge diagnosis: Atrioventricular heart, block probably congenital in origin.

CODE: _____________________

2. The patient, a 2 month old male infant, was referred for evaluation of a faulty Airway. The mother reported she had had noisy breathing since birth and that it had worsened recently. Severe to moderate laryngomalacia was identified on a flexible bronchoscopy. A supraglottostomy with repair of larynx was performed without complications during the procedure or after word. The patient received antibiotic postoperatively and was discharged in good condition. 

Discharge diagnosis:  Laryngomalacia.

CODE:____________________

3. The patient, a 2 year old male, has congenital bilateral clubfoot and atretic spinal cord at level T11- L4. He needed a walker to ambulate, using mostly the upper extremities to get around. He was admitted for repair of a left tibial torsion. A tibial rotational osteotomy was performed, with insertion of pins. He was placed in a splint postoperatively and was changed to a long leg cast the next day. The patient was discharged subsequently to follow up with the orthopedic surgeon in 1 week. 

Discharge diagnosis: Atretic spinal cord and T11-L4 with left Tibial torsion.

CODE:___________________

4. The patient, a 20 month old girl, was admitted for correction of a left talipes equinovarus clubfoot. Shortly after admission, she started running a fever and it became apparent that she had acute otitis media. She was placed on antibiotics and discharge. Surgery was to be rescheduled at a later date.

Discharge diagnosis: ( 1.) talipes equinovarus left; (2.) bilateral otitis media 

CODE:____________________

5. The patient, a teenage male, was referred by his orthodontist for surgical correction of multiple congenital deformities. Examination revealed maxillary hypoplasia and maxillary asymmetry. He was found to have an excessive cross-bite, with the maxillary midline several millimeters to the right. Surgical correction was indicated and the plan was to perform both maxillary and mandibular osteotomies to achieve the amount of movement needed. During surgery, it was possible to move the left maxilla into its desired position without a mandibular osteotomy being performed. Postoperatively, he did very well. 

Discharge diagnosis: (1.) maxillary hypoplasia, (2.)  maxillary asymmetry, (3.) excessive crossbite. 

Procedure performed; segmental maxillary osteotomy

CODE:______________________

6. The patient, a 10 month old infant, had the genital extrahepatic biliary atresia. She was admitted for a liver transplant work up and admission was in chronic liver failure. The workup included a chest x-ray KUB study, Doppler ultrasound of liver, and EKG, as well as in upper GI endoscopy of the esophagus, stomach, and duodenum.

Discharge diagnosis: (1.) extrahepatic biliary atresia, (2.) place on liver transplant list stage 2

CODE: _________________________

ICD-10-CM and ICD-PCS- CODING HANDBOOK, WITHOUT ANSWERS, 2022 REVISED EDITION 

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